Demographics / Health History
Note
: this form must be completed and submitted
online
- it is not able to be printed
Patient Information
Patient Legal Name
*
Birthdate
*
Gender
*
(as indicated by insurance company)
Male
Female
Social Security No.
Patient Phone
*
Is patient over 18 years of age?
*
Yes
No
Do you have a Guardian?
Yes
No
Patient Address
*
City
*
State
*
Zip
*
Reason for Visit
*
Who Referred You?
First Name
Last Name
Phone
or Facility Name
or Other Name
Location of Facility/Other (address or nearest crossroads)
Who is your Primary Care Physician (PCP)?
First Name
*
Last Name
*
Facility
Phone
*
Parent Information
Mother
First Name
*
Last Name
*
MI
Birthdate
*
Social Security No.
*
(req'd for insurance purposes)
Phone
*
Daytime Phone (if different)
Email
*
Mother Employed?
Yes
No / Stay-at-home Parent
Employer Name
Occupation
Work Phone
Mother’s address same as Patient’s?
*
Yes
No
Mother Address
City
State
Zip
Father
First Name
*
Last Name
*
MI
Birthdate
*
Social Security No.
*
(req'd for insurance purposes)
Phone
*
Daytime Phone (if different)
Email
*
Father Employed?
Yes
No / Stay-at-home Parent
Employer Name
Occupation
Work Phone
Father’s address same as Patient’s?
*
Yes
No
Father Address
City
State
Zip
Parent's Marital Status
*
Married
Divorced
Separated
Widowed
Single
Other
Emergency Contact
First Name
*
Last Name
*
Is this person older than 18 years?
*
Yes
No
Daytime Phone
*
Home
Cell
Relationship to Patient
*
Insurance Information
Primary Insurance
Do you have insurance (including Medicaid and Medicare)?
*
Yes
No
–
I am declaring I am self-paying for services rendered
This section must be completed in order for us to bill your insurance company AND to schedule any surgeries.
Insurance Name
*
Policy No.
*
Group No.
*
Address
City
State
Zip
Who is the insurance cardholder?
*
Mother
Father
Self
Other
Subscriber/Cardholder:
First Name
*
Last Name
*
Relationship
*
Birthdate
*
Social Sec. No.
*
(required for insurance purposes)
Subscriber/Cardholder Address
*
City
*
State
*
Zip
*
Employer Name
*
Employer Phone
*
Employment Status
Full Time
Part Time
Do you have secondary insurance (including Medicare and Medicaid)?
*
Yes
No
Secondary Insurance
Insurance Name
*
Policy No.
*
Group No.
*
Address
City
State
Zip
Who is the insurance cardholder?
*
Mother
Father
Self
Other
Subscriber/Cardholder:
First Name
*
Last Name
*
Relationship
*
Birthdate
*
Social Sec. No.
*
(required for insurance purposes)
Subscriber/Cardholder Address
*
City
*
State
*
Zip
*
Employer Name
*
Employer Phone
*
Employment Status
Full Time
Part Time
Reason for Appointment
Injury / Broken Bone / Continued Pain
Location
Right
Left
Bilateral (both sides)
Upper Extremity
Collarbone
Shoulder
Upper Arm
Elbow
Forearm
Wrist
Hand
Finger
Other
Please specify
Lower Extremity
Hip
Upper Leg
Knee
Lower Leg
Ankle
Foot
Toe
Other
Please specify
What is the date of injury?
or unknown
Is this a sports-related injury?
Yes
No
Name of school/club
Is this the result of an auto accident?
Yes
No
Were xrays taken?
Yes
No
Do you have them with you?
Yes
No
From which facility?
AdventHealth/Centracare
Olathe Health
Children’s Mercy ED/Urgent Care
St Luke’s Health System
Physicians Now
Other
Please Specify
Where did the injury occur?
Home
Which Room?
Yard
School
Pool
Driveway
Sidewalk
Street
Field / Court
Other
Please Specify
What type of field or court?
Baseball
Football
Basketball
Soccer
Other
What was the patient doing when the injury occurred?
Cerebral Palsy / Stroke / Hemiplegia
Issues during pregnancy
Issues unknown (adopted)
IVF
Bedrest
High blood pressure
Unplanned emergency C-section
Delivery
Full term (38 - 41 weeks)
Premature
Born at
weeks
Did the child go home from the hospital with you?
Yes
No
How many weeks in NICU?
Did your child have a ventilator (tube down the throat) in the NICU?
Yes
No
Did your child receive cold therapy?
Yes
No
Did your child have an MRI or US showing a brain bleed?
Yes
No
Did your child have an MRI showing PVL?
Yes
No
Does your child have a G-tube?
Yes
No
Did your child have a tracheostomy?
Yes
No
Other delivery issues?
Does your child have any seizures?
Yes
No
Does your child receive therapy?
Physical Therapy
From who?
Occupational Therapy
From who?
Speech-Language Therapy
From who?
What are your goals for your child?
What are your goals for seeing me?
Does your child wear braces?
Yes
No
What kind?
DAFOs
AFOs
SMOs
Last time they were molded (mm/yyyy)
Has anyone taken hip xrays of your child?
Yes
No
When?
Where?
Do you have the images?
Yes
No
Do you or your Therapist have any concerns about curvature of the back (Scoliosis or Kyphosis)?
Yes
No
Does your child sleep through the night?
Yes
No
Does your child have trouble falling asleep?
Yes
No
Does your child wake up after midnight and stay awake for two to three hours?
Yes
No
Has any provider checked a vitamin D level?
Yes
No
Number
Date checked
(
unknown)
Has your child ever received a recommendation for botulinum toxin injections (Botox® / Myobloc® / Dysport®)?
Yes
No
Who recommended the injections?
First Name
Last Name
Facility
Has your child been injected?
Yes
No
Do you know the muscles injected?
Yes
No
Date injected
(if known)
Location
(i.e. clinic, hospital)
Does your child have daily bowel movements (without Miralax® or laxatives)?
Yes
No
Please specify type
Does your child strain when trying to poop?
Yes
No
Is your child potty trained?
Yes
No
Abnormal Walking / Movement
Do you have concerns about
Foot
Knee Position
Leg Position
Toe Walking
Running Style
Concerns are from (check all that apply)
Mom
Dad
Grandparents
Primary Care provider
How long has this been going on?
1 to 2 weeks
2 to 4 weeks
1 to 2 months
2 to 4 months
Greater than 4 months
Please check all previous treatment(s) you’ve had for this current problem if applicable
Physical Therapy
Bracing
Surgery
Anti-Inflammatories/NSAIDS
Medications not previously listed
Chiropractor
None
Other Treatments
Please specify
Have you had any of the following diagnostic studies for your current problem?
CT
Yes
No
Where
When
MRI
Yes
No
Where
When
If having pain, please have the child rate the pain by pointing to the picture that best describes the pain
0
1-2
3-4
5-6
7-8
9-10
Pain Description:
Aching
Burning
Dull
Numbness
Pressure
Sharp
Shooting
Throbbing
Tingling
Unable to Describe
Other
Do any of the following activities make it worse? (Check all that apply)
Activities of Daily Living
Exercise
Standing
Walking
Other
Please describe
Developmental History (if less than 5 years old)
Can your child sit?
Yes
No
When began
Normal (4-6 months)
Late
Early
Can your child
Crawl
Stand independently
Walk independently
Keep up with other children of same age
Other Information
What is your child’s pain threshold?
High
Normal
Low
How do you know this?
Do you have to cut tags out of your child’s clothing?
Yes
No
Medications
Allergies to medications, X-ray dye, metals and/or soaps?
NKDA (No Known Drug Allergies)
Yes, please list and indicate reaction
Name
Reaction
Name
Reaction
Name
Reaction
Name
Reaction
Please list any food allergies (i.e. gluten, milk intolerance, etc.)
Is the child currently taking prescribed medications or over-the-counter supplements?
Yes
No
Please list all current medications and dosages, or bring current list to your scheduled appointment
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Add more meds?
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Name
Dosage
Frequency
Pharmacy Name
Phone
Address
City
State
Zip
Social History
Any potential exposure to Smoking/Smokeless Tobacco, Vaping/E-cigarettes in the home?
Yes
No
Family History
(check where applicable) –
Unknown - child is adopted
Anesthesia Problems
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
Cancer -
Type
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
Bleeding/Clotting (DVT)
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
Diabetes
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
Heart Disease
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
High Blood Pressure
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
Malignant Hyperthermia
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
Stroke
None
Father
Mother
Grandfather
Grandmother
Other (i.e. Aunts / Uncles)
Patient Past Medical History
- check all that apply
Heart Disease
Learning Issues/ADHD/ADD
- Specify
Lung Disease
Asthma
Diabetes
Gastric Ulcer / Reflux / Heartburn
Anxiety
Depression
Stroke
High Blood Pressure
Kidney Disease
Blood Disorder
Thyroid Disorder
Liver Disease
Skin Infection
Reaction to Anesthesia
Other
- Specify
Other
- Specify
Procedure / Surgery History
Please list all past procedures / surgeries -
None Apply
Orthopaedic
Procedure
Date (month/year)
Hospitalization-Dehydration
Date (month/year)
Hospitalization-RSV
Date (month/year)
Hospitalization-Seizures
(month/year)Date
Appendectomy
(month/year)Date
Sinus
(month/year)Date
Tonsils
(month/year)Date
Tubes (ear)
(month/year)Date
Other
Procedure
Date (month/year)
Is there anything else you would like POSA to know about your child?
Yes
No